A senior dispatcher said: ‘We used to have ambulances waiting for calls, now we have a stack of calls that are waiting for ambulances.’
Photograph: Matt Cardy/Getty Images

A 20-year-old woman with a ruptured spleen died after waiting 85 minutes for an ambulance because of a series of mistakes at an under-pressure control room, an inquest has heard.

At one stage while Kathryn Richmond lay in agony and struggling for breath, four of the 13 ambulances for her area were off-road as crews had meal breaks.

Her emergency call was downgraded twice in the 85 minutes, resulting in two ambulances that were on their way to her being diverted elsewhere.

When the university student from Poole in Dorset eventually got to hospital, she went into cardiac arrest. She underwent emergency surgery but could not be saved.

The senior coroner for Dorset, Rachael Griffin, will write to the health secretary, Jeremy Hunt, recommending that rotas and meal breaks for ambulance crews across the UK be staggered.

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Andy Smith, executive medical director at South Western ambulance service NHS foundation trust, said: “[We] would like to again extend sincere condolences to Kathryn Richmond’s family. We are very sorry that we did not arrive to treat Kathryn in time. We have since made significant changes to our systems to minimise the risk of this happening again.”

Richmond had a ruptured spleen caused by a rare complication from glandular fever and collapsed at home just after midnight on 21 April 2015.

Her parents, Alan and Jacqueline, called 999 at 12.14am and the case was listed as “red 2”, meaning an ambulance should have reached her within eight minutes.

Although one was dispatched at 12.15am, a call handler downgraded the case and the ambulance was diverted to another emergency. Richmond’s parents called a second time at 12.40am to find out where the ambulance was and the case was relisted as a red 2.

Another ambulance was called off when a clinical supervisor, Duncan Smith, reviewed the call and downgraded it again.

The inquest in Bournemouth heard that Smith made the mistake of “fixating” on an assumed diagnosis that Richmond was hyperventilating, when further investigation by him would have revealed she was in hypovolemic shock owing to blood loss. Paramedics finally arrived at 1.39am and Richmond died at 6.22am.

Asked by the coroner whether he felt under pressure to downgrade the call, Smith said: “Yes, there is some pressure, more so in the Dorset hub because the dispatchers would be sat 2ft in front of me, looking at me, asking if that call is going to be red.

“That pressure is quite direct. They are having trouble making a response time. I know they want you to look at that call urgently because they are not going to make it.”

He added: “I did feel under pressure, but that did not impact upon my clinical decisions.”

Nicholas McGuinness, the senior dispatcher at the hub on the night in question, also said there was a lot of pressure on staff as they did not have enough ambulances.

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“We used to have ambulances waiting for calls, now we have a stack of calls that are waiting for ambulances. Decisions have to be made about which calls we will go to first,” he said. “The amount of resources we are provided with is far lower than we need to safely deal with the amount of calls we receive in this area.”

The coroner recorded a narrative verdict. She said: “The cause of Kathryn’s death was a natural cause because she had glandular fever. However, the delay in her receiving the necessary life-saving treatment was causative or contributory to her death.

“The delay was due to individuals’ judgments, assessments and mistakes – those are not system failures. There are a number of issues which give me concerns but considerable effort has been made to address those.”

The coroner accepted that the meal breaks issue had not led to Richmond’s death, and acknowledged that the ambulance service had since made changes.

The ambulance service added that the meal breaks were “protected” ones that could not be interrupted except for a “red 1” call. It said demand on the night was 20% more than predicted.